REVERT – The Modified Valsalva Maneuver

Background

Supraventricular tachycardias (SVT) (excluding atrial fibrillation and atrial flutter) are common cardiac arrhythmias leading to presentation to the Emergency Department (ED). The Valsava maneuver is a recommended first-line method to cardiovert stable patients, but its reported efficacy is low (5-20%). Chemical cardioversion agents can have unpleasant side effects and require intravenous access. Increasing the success rate from the Valsava maneuver could lead to increased patient comfort and decreased resource utilization.

Clinical Question

Is a modified Valsava maneuver more effective than a standard Valsava maneuver at restoring sinus rhythm in patients presenting to the Emergency Department with supraventricular tachycardias?

Intervention

Control

15 seconds Valsava maneuver while sitting semi-recumbent

Outcomes

Outcome (Primary): Restoration to sinus rhythm at 60 seconds after initiation of Valsava maneuverOutcomes (Secondary): Use of adenosine, use of any emergency treatment for SVT including adenosine, need and reason for admission to hospital, length of time participants spent in ED, adverse events.

Limitations

Author's Conclusions

“In patients with supraventricular tachycardia, a modified Valsava manoeuvre with leg elevation and supine positioning at the end of the strain should be considered as a routine first treatment, and can be taught to patients.”

Our Conclusions

There is evidence that the modified Valsava maneuver described in this study can significantly increase the likelihood of conversion to sinus rhythm when used in stable adult patients presenting in SVT. The maneuver has the potential to decrease patient discomfort and resource utilization, and can potentially be taught to patients with recurrent episodes of SVT and prevent ED visits.

Potential Impact To Current Practice

The proposed intervention was found to be effective and has no cost. This technique can be brought to clinical practice immediately.

Bottom Line

Evidence is shown that the modified Valsava maneuver has increased conversion rates compared to standard Valsava, and should be considered as a primary method of cardioversion for stable patients presenting in SVT.